Breech Presentation

The fetus presents with the buttocks or feet, rather than the head, closest to the cervix.

Present in roughly 3 to 4% of pregnancies at term, though considerably more common earlier in pregnancy given that most fetuses spontaneously turn to cephalic presentation by around 36 weeks.

Classified as frank breech (hips flexed, knees extended, feet by the head, most common), complete breech (hips and knees both flexed), and footling breech (one or both feet presenting below the buttocks, carrying the highest cord prolapse risk).

Fetal head palpable at the fundus, with a softer, less well-defined presenting part in the pelvis.

Often first identified on routine antenatal examination or a scan performed for another indication.

Ultrasound confirms presentation and type, assesses for a cause where one may exist (placenta praevia, uterine anomaly, fetal anomaly, polyhydramnios or oligohydramnios), and, if external cephalic version or vaginal breech birth is being considered, assesses fetal size, head flexion, and estimated fetal weight.

• External cephalic version (ECV) is offered from around 36 weeks in nulliparous women and 37 weeks in multiparous women, for persistent breech presentation without contraindication (major uterine anomaly, ruptured membranes, significant antepartum hemorrhage in the current pregnancy, multiple pregnancy other than after delivery of the first twin, or a fetal heart rate abnormality); success rate is roughly 40 to 60%, higher in multiparous women; a tocolytic (nifedipine or a beta-agonist such as terbutaline) may be used to relax the uterus and improve success
• Anti-D prophylaxis for Rh negative women undergoing ECV given the risk of fetomaternal hemorrhage
• If breech presentation persists, options are planned cesarean section or planned vaginal breech birth, following shared decision-making; planned cesarean is associated with a small reduction in short-term neonatal morbidity but does not clearly improve long-term outcomes, and vaginal breech birth remains a reasonable option in appropriately selected women (frank or complete breech, adequate pelvis, estimated fetal weight appropriate, no hyperextension of the fetal head) managed by an experienced practitioner
• Vaginal breech birth requires continuous fetal monitoring, an experienced accoucheur, and immediate access to cesarean facilities, given the risks of cord prolapse (particularly footling breech), head entrapment, and birth trauma
• Footling breech in labor, or breech presentation with a contraindication to vaginal birth, is delivered by cesarean

Referral: obstetric-led care; specialist counseling for ECV and mode of delivery decision-making.